Drinking During Adolescence

For many people, experience with drinking alcohol begins in adolescence. Yet for some youth, such early experimentation can spiral into problematic drinking patterns. Research has associated a variety of serious health risks with adolescent drinking, including the three leading causes of death among this age group (i.e., unintentional injuries, homicide, and suicide) as well as unsafe sexual behavior. Although alcohol abuse and dependence are not often clinically diagnosed among youth of high school age and younger, it is possible that applying adult diagnostic criteria does not fully capture the extent of adolescent problem drinking. Risk factors for adolescent drinking encompass sociocultural factors, such as regulation of alcohol availability; parental behavior and drinking patterns; the influence and drinking habits of siblings and peers; personality traits, particularly those indicating low self-regulation; and positive beliefs about alcohol’s effects. More research is necessary, however, to distinguish the factors that can predict adolescent problem drinking from those that predict consumption in general.

R esearchers typically consider adolescence to be the developmental period during which youth are most at risk for initiating alcohol use. Many developmental theorists view adolescence as occurring from approximately age 10 (i.e., the beginning of pubertal development) through age 25 (i.e., when adult roles are established) (Feldman and Elliott 1990). This article, however, applies a more restric tive definition and primarily considers alcohol consump tion from early adolescence through the high school years (i.e., approximately ages 10 to 18).
Prevalence data suggest that most adolescents report some exposure to alcohol use and that use increases with age (Johnston et al. 1995). In terms of current consump LAURIE CHASSIN, PH.D., is professor of psychology and CHRISTIAN DELUCIA is a graduate research assistant in the Psychology Department, Arizona State University, Tempe, Arizona.
The preparation of this article was supported by National Institute on Drug Abuse grant DA05227 to Laurie Chassin, Ph.D., and Manuel Barrera, Jr., Ph.D.
tion, recent national student survey data (see figure 1) show that 25 percent of 8th graders and 50 percent of 12th graders report consuming alcohol within the past month (Johnston et al. 1995). Moreover, a substantial pro portion of those drinkers consume heavily: 1 15 percent of the 8th graders and 28 percent of the 12th graders report having five or more drinks in a row in the past 2 weeks, and just under 3 percent of the 12th graders report daily use. National surveys have found some gradual declines in adolescent drinking since the peaks of the early 1980's, but the most recent trends, which show some small (i.e., not statistically significant) increases (Johnston et al. 1995), are less clear.
The prevalence of adolescent drinking also varies demographically. Boys report more heavy drinking than do girls, and among high school seniors, white adoles cents report more heavy drinking than do Hispanic or AfricanAmerican adolescents. For example, 1994 na tional data for 12th graders (see figure 2) found that 32 percent of nonHispanic Caucasians, 24 percent of His panics, and 14 percent of AfricanAmericans reported consuming five or more drinks in a row in the past 2 weeks (Johnston et al. 1995). However, because these ethnic differences are less apparent at earlier grades, they could be caused partially by ethnic differences in school dropout rates (Johnston et al. 1995). (Schoolbased surveys collect data on current students only; thus, these surveys cannot determine the alcohol consumption patterns of sameage school dropouts. To the degree that dropout rates vary by ethnicity, the survey results will be skewed.) Inconsistent definitions, as well as inter and intracultural diversity, complicate comparisons among ethnic groups. In general, however, compared with other ethnic groups, Native American adolescents typically report the highest con sumption rates, and AsianAmerican youth report the lowest (Johnstone 1994).

DIAGNOSIS OF ALCOHOL ABUSE AND DEPENDENCE AMONG ADOLESCENTS
As with adult alcohol use, an examination of adolescent drinking patterns and problems requires consideration of (1) the quantity and frequency of consumption, (2) alcohol related negative life consequences, and (3) alcohol dependence symptoms (Bailey and Rachal 1993). Beyond the examination of simple consumption patterns, however, a striking lack of empirical work exists on the prevalence of clinical alcohol abuse or dependence 2 among adoles cents of high school age or younger. This void likely is attributable to the low prevalence of alcohol abuse and dependence diagnoses in early and middle adolescence 1 The term "heavy alcohol consumption" is not used consistently in the alcohol research literature, and the studies referred to in this article like wise define the concept in different ways. Unless otherwise specified, this article defines heavy consumption as having five or more drinks in a row within the past 2 weeks. 10th 12th

Student Grade Level
Consumed alcohol in past month Drank heavily (consumed 5+ drinks in a row in past 2 weeks) Past-month and heavy drinking among 8th, 10th, and 12th graders (1994). SOURCE: Johnston et al. 1995, p. 43.

Figure 1
compared with the dramatic increase in alcohol problems after the high school years. For example, Cohen and col leagues (1993) found prevalence rates 3 of 4 percent or less among adolescents younger than age 16. In contrast, prevalence rates of 8.9 percent and 20.3 percent, respec tively, were found for females and males ages 17 to 20 (Cohen et al. 1993). Simply applying adult diagnostic criteria, however, may not be the best way to describe the drinking patterns and problems that occur during early and middle adoles cence. Using other measures, the discrepancy between prevalence rates for younger and older adolescents could diminish. For example, Martin and colleagues (1995) found that common adult symptoms of alcohol abuse and dependence, such as medical problems and alcohol with drawal symptoms, rarely occurred in adolescents. In addition, many adolescents who did not have an alcohol dependence diagnosis reported a marked increase in the amount of alcohol needed to attain a desired effect (i.e., tolerance). In fact, Martin and colleagues (1995) suggest 2 Definition of the terms "alcohol abuse" and "alcohol dependence" can vary in the alcoholism literature. Generally, however, a person clinically diagnosed with alcohol abuse or alcohol dependence must meet specific criteria (e.g., as defined in the American Psychiatric Association's Diag nostic and Statistical Manual of Mental Disorders, Fourth Edition). These criteria include the experience of withdrawal symptoms and in creased tolerance to the effects of alcohol as well as impaired control over drinking. that a marked increase in consumption may be a nor mative feature of adolescent drinking rather than a phe nomenon linked specifically to alcohol dependence. Research is now under way to refine methods for diag nosing clinical alcohol abuse and dependence in adoles cents (Martin et al. 1995).

CONSEQUENCES OF ADOLESCENT DRINKING
Adolescent alcohol use (particularly heavy use) is associ ated with many negative outcomes (see table 1). Although medical consequences of alcohol abuse in adolescents are rarely studied, a few studies have produced evidence that describes such effects. For example, adolescent alcohol abusers show elevations in liver enzymes (Arria et al. 1995), an early indicator of liver damage. These adoles cents also demonstrate higher rates of multiple drug use (Arria et al. 1995) and poorer language function than do adolescents without alcohol abuse or dependence diag noses (Moss et al. 1994). However, they do not show signs of brain damage on neuropsychological tests (Moss et al. 1994).
Perhaps of even greater public health significance is the fact that adolescent alcohol consumption is correlated with the three leading causes of death in this age group: unintentional injuries, homicide, and suicide (U.S. Depart ment of Health and Human Services [USDHHS] 1991). More than onehalf of all fatal motor vehicle crashes among 15 to 24yearolds involve alcohol, and approxi mately onehalf of all homicides in this age group are associated with alcohol use (USDHHS 1991). Moreover, the percentage of intoxicated drivers involved in fatal crashes is higher at younger ages, reaching a peak among young adults (i.e., 34 percent for drivers ages 21 to 24 in 1991), then declining among older adults (i.e., 16 percent for drivers ages 45 to 64 in 1991) (National Center for Statistics and Analysis 1992). National data also suggest that alcohol use was associated with suicidal thoughts and suicide attempts among the 8th and 10th graders who were surveyed (Windle et al. 1992).
The association between adolescent alcohol consump tion and risky sexual behavior also is of public health importance. Adolescent alcohol use is associated with earlier initiation of sexual activity, more frequent sexual activity, and less frequent condom use (Cooper et al. 1994), all of which raise the risk for HIV infection and other sexually transmitted diseases. In addition, adoles cents (particularly white adolescents) report riskier sexu al behavior on occasions when they have used alcohol or other drugs (AOD's) than on occasions when they have not (Cooper et al. 1994).
However, the association between adolescent drinking and these serious negative health risks does not imply a causal relationship. As other researchers have indicated (Donovan 1993; Leigh and Stall 1993), adolescent alco hol use is associated with personality characteristics such  as impulsiveness and sensation seeking. Thus, it may be these underlying personality characteristics, rather than simply alcohol use, that increase the risk for traffic crashes, risky sexual behavior, violence, and suicide. A similar argument has been made concerning the relationship be tween alcohol use and other drug use. Alcohol is used at earlier ages than are other drugs, and alcohol use increases the risk for later use of illegal drugs (Yamaguchi and Kandel 1984). Early onset of alcohol use (i.e., before age 15) is associated with greater risk for other substance use and the development of later alcoholrelated problems (Robins and Pryzbeck 1985). However, although alcohol, like cigarettes, may lead to other forms of substance use, this pattern does not imply that alcohol use "causes" such substance use.
In terms of psychosocial development, Baumrind and Moselle (1987) speculate that heavy AOD use in adoles cence interferes with the development of emerging ado lescent competencies, including social and coping skills. Because most adolescents report some alcohol use, how ever, these deficits may be limited to those adolescents who drink particularly heavily or frequently. In fact, in the general population, drinking in adolescence has been associated with enhanced social functioning, less loneli ness, and more positive emotional states (i.e., positive affect) in early adulthood (Newcomb and Bentler 1988

Sociocultural Factors
One sociocultural factor affecting adolescents is their degree of access to alcohol. Although few studies have focused specifically on adolescents (Holder 1994), the existing research suggests that greater alcohol availability is associated with higher rates of drinking. In contrast, greater regulation of alcohol availability is associated with older ages of initiation, decreased consumption, and fewer alcoholrelated problems (Single 1994). In particu lar, computer simulations indicate that policies raising the legal drinking age or increasing prices with alcohol taxes are associated with lower rates of adolescent alcohol consumption and reduced mortality from traffic crashes among youth ages 18 to 20 (Grossman et al. 1994). Re search on other sociocultural factors, such as the impact of alcohol advertising and alcohol warning labels, is equiv ocal and has produced limited data on adolescents (Mac Kinnon 1995; Single 1994).

Family Factors
Many theories (e.g., social control theory, social learning theory, and problem behavior theory) include a focus on family factors that influence adolescent alcohol use (Jacob and Leonard 1994). Empirical studies have produced fairly consistent support for these theories. Families in which parents use alcohol to excess, show high levels of antisocial behavior (including antisocial personality dis order 4 ), or both are said to model alcoholabusing behav ior, a factor termed "family modeling." These families are more likely to have adolescent children who use al cohol (see the article by Windle on parental alcoholism, pp. 181-184). Families in which parents provide low levels of social support, show little monitoring of their children's behavior, use inconsistent discipline practices, and exhibit high levels of conflict and low levels of closeness-traits known as family socialization factorsalso are more likely to have adolescent children who use alcohol (Barnes et al. 1986). Most empirical studies have been conducted with biological families, however, which may lead to overestimating the magnitude of such family influences, because the behavior of offspring reflects shared genes as well as shared environment (McGue et al. 1996). (In contrast, studies of adoptees can help iso late environmental factors from genetic ones.) Potentially important components of family influence on adolescent drinking are the drinking behavior and

Poorer language function
Interference with development of adolescent competencies Interference with development of social and coping skills social influence of siblings (Jacob and Leonard 1994). Siblings' levels of alcohol consumption are correlated for both biological and adoptive siblings. These correlations are stronger for siblings who are close in age and of the same sex (McGue et al. 1996). Siblings may provide direct modeling influences as well as more indirect influ ences through exposure to a particular highrisk peer group (Rowe and Gulley 1992).

Peer Factors
Peer drinking and peer acceptance of drinking (i.e., posi tive attitudinal tolerance of drinking) have been consis tently associated with adolescent drinking, and adolescent drinking typically occurs in peer social contexts (Hughes et al. 1992;Margulies et al. 1977). Adolescents whose friends frequently drink are more likely to increase their own drinking over time, and adolescents who frequently drink are more likely to increase their affiliations with alcoholusing peers (Curran et al. in press). Thus, adoles cents who drink are more likely to select friends who drink, and those friends in turn influence adolescents' drinking. In understanding adolescents' risk for drinking, one must consider what leads adolescents to affiliate with alcoholusing peers. Some research suggests that poor parenting practices create early childhood deficits in social skills and selfregulation, particularly with regard to ag gressive behavior, which result in rejection from main stream peer groups (Brown et al. 1993;Patterson et al. 1989). Children who are rejected from these mainstream peer groups then affiliate with deviant peers; in turn, participation in deviant peer networks increases the risk for drinking and other forms of substance use (Kaplan 1980). This research demonstrates a link between the parenting factors and the peer factors that lead to ado lescent drinking.

Intrapersonal Factors
Adolescents who report high levels of alcohol consump tion are characterized by a constellation of personality traits indicating low levels of selfregulation (see table 2). These adolescents are more likely to be aggressive and to have high attitudinal tolerance for deviant behavior, low value and expectations for academic success, and high levels of sensation seeking and impulsivity (Brook et al. 1992;Jessor and Jessor 1977). These characteristics also describe adolescents with clinical levels of alcohol abuse or dependence (Moss and Kirisci 1995).
The role of other intrapersonal factors is more contro versial. For example, it is unknown whether intense emo tional responses and a tendency to overreact (i.e., emotional reactivity) or negative emotional states, such as depression and anxiety, are linked to adolescent alcohol use. Some data link negative emotional states, particularly depression, to adolescent alcohol use (Colder and Chassin 1993;Hussong and Chassin 1994). However, studies over time that attempt to predict later alcohol use based on previously measured levels of negative emotional states do not always confirm this relationship (Chassin et al. 1996). Thus, it is unclear whether negative emotional states are a cause or a result of adolescent alcohol use, although depressive disorders (Deykin et al. 1992) and anxiety disorders (Clark et al. 1994) have been associated with clinical alcoholism in adoles cence. Moreover, the combination of low selfregulation and high levels of negative emotional states (i.e., negative affect) may be associated particularly with adolescent alcohol use (Pandina et al. 1992).
The onset of adolescent alcohol use among middle school students also has been linked to low levels of self esteem (Kaplan 1980). According to Kaplan's self derogation theory, adolescents who receive failure feedback from mainstream sources (e.g., peer rejection or poor school achievement) seek out deviant peer affil iations in order to increase their sense of selfworth. Although these deviant peer affiliations do raise self esteem, they also raise risk for AOD use.

Beliefs About Alcohol
Adolescents form beliefs about alcohol's effects before actually engaging in alcohol consumption, and these expectations (i.e., alcohol expectancies) are related to their drinking behavior. For example, Christiansen and colleagues (1989) found that positive expectancies of alcohol predicted adolescents' drinking behavior (and problem drinking) 12 months later. Moreover, among 12 to 14yearold abstainers, adolescents who expected to gain greater social acceptance (i.e., social facilitation) as a result of drinking were more likely to begin to drink, and they increased their alcohol consumption at faster

Possible Other Characteristics
Negative emotional states (e.g., depression)

High emotional intensity
Low threshold for emotional response rates than did their sameage peers who did not show these expectancies (Smith et al. 1995). Alcohol ex pectancies are a potentially important risk factor for adolescents, because they may integrate adolescents' knowledge about alcohol from sources such as media, peer, and family models as well as from their own ex periences. Thus, many different influences can shape adolescents' beliefs about alcohol, and these beliefs in turn influence adolescents' drinking behavior.

SUMMARY AND CONCLUSIONS
Understanding alcohol use in adolescence is critical, because during these years, many people initiate drink ing, and early drinking problems can appear. Although some experimentation with drinking is virtually universal and normative in adolescence, alcohol use during this period also is linked to negative adolescent health out comes, including unintentional injuries, homicide, sui cide, and unsafe sexual practices. At a broad social level, adolescent drinking is related to alcohol availability as well as to laws, social norms, and prices regulating such availability. In addition, adolescents who drink alcohol are more likely to come from families in which parental drinking, sibling drinking, and lower levels of parental control and support occur. Youth who drink also are more likely to have friends who model and tolerate alco hol use, show lower levels of selfregulation, and have more positive expectancies about alcohol's effects. Much of the research to date, however, has related these risk factors to the frequency or quantity of drinking rather than to alcohol abuse or dependence among adolescents. Thus, it has been difficult to distinguish predictive fac tors specific to adolescent problem drinking or clinical alcohol abuse or dependence from predictors of alcohol consumption in general. An understanding of the factors that determine which adolescents are particularly vulner able to the negative effects of alcohol consumption is an important step for preventing alcoholrelated problems among adolescents. ■